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Salhi RA, Macy ML, Samuels-Kalow ME, Hogikyan M, Kocher KE. Frequency of Discordant Documentation of Patient Race and Ethnicity. JAMA Netw Open 2024; 7:e240549. [PMID: 38466310 DOI: 10.1001/jamanetworkopen.2024.0549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
This cohort study examines longitudinal changes in race and ethnicity assignment in US hospitals.
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Affiliation(s)
- Rama A Salhi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Michelle L Macy
- Division of Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research and Evaluation Center, Stanley Manne Children's Research Institute, Chicago, Illinois
| | | | - Megan Hogikyan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
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Barron R, Mader TJ, Knee A, Wilson D, Wolfe J, Gemme SR, Dybas S, Soares WE. Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial. Ann Emerg Med 2024; 83:123-131. [PMID: 38245227 DOI: 10.1016/j.annemergmed.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 01/22/2024]
Abstract
STUDY OBJECTIVE Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores. METHODS In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison. RESULTS All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66). CONCLUSION Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.
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Affiliation(s)
- Rebecca Barron
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA.
| | - Timothy J Mader
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Alexander Knee
- Department of Medicine, UMass Chan Medical School-Baystate, Springfield, MA; Epidemiology Biostatistics Research Core, Office of Research, Baystate Medical Center, Springfield, MA
| | - Donna Wilson
- Epidemiology Biostatistics Research Core, Office of Research, Baystate Medical Center, Springfield, MA
| | - Jeannette Wolfe
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Seth R Gemme
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | | | - William E Soares
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
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Titus BR, Ream KS, Rehman T, Allen LA. Sex-disparities in chest pain workup: a retrospective cohort review of a university based clinical decision pathway. BMC Cardiovasc Disord 2023; 23:620. [PMID: 38114900 PMCID: PMC10729513 DOI: 10.1186/s12872-023-03610-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Females have historically lower rates of cardiovascular testing when compared to males. Clinical decision pathways (CDP) that utilize standardized risk-stratification methods may balance this disparity. We sought to determine whether clinical decision pathways could minimize sex-based differences in the non-invasive workup of chest pain in the emergency department (ED). Moreover, we evaluated whether the HEART score would minimize sex-based differences in risk-stratification. METHODS We conducted a retrospective cohort review of adult ED encounters for chest pain where CDP was employed. Primary outcome was any occurrence of non-invasive imaging (coronary CTA, stress imaging), invasive testing, intervention (PCI or CABG), or death. Secondary outcomes were 30-day major adverse cardiac events (MACE). We stratified HEART scores and primary/secondary outcomes by sex. RESULTS A total of 1078 charts met criteria for review. Mean age at presentation was 59 years. Females represented 47% of the population. Low, intermediate, and high-risk patients as determined by the HEART score were 17%, 65%, and 18% of the population, respectively, without any significant differences between males and females. Non-invasive testing was similar between males and females when stratified by risk. Males categorized as high risk underwent more coronary angiogram (33% vs. 16%, p = 0.01) and PCI (18% vs. 8%, p = 0.04) than high risk females, but this was not seen in patients categorized as low or intermediate risk. Males experienced more MACE than females (8% vs. 3%, p = 0.001). CONCLUSIONS We identified no sex-based differences in risk-stratification or non-invasive testing when the CDP was used. High risk males, however, underwent more coronary angiogram and PCI than high risk females, and consequently males experienced more overall MACE than females. This disparity may be explained by sex-based differences in the pathophysiology driving each patient's presentation.
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Affiliation(s)
- Benjamin R Titus
- Internal Medicine Residency, University of Colorado, Aurora, United States.
| | - Karen S Ream
- Division of Cardiology, University of Colorado, Aurora, United States
| | - Tehreem Rehman
- Department of Emergency Medicine, Mount Sinai Hospital, New York City, United States
| | - Larry A Allen
- Division of Cardiology, University of Colorado, Aurora, United States
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McLaren JTT, El-Baba M, Sivashanmugathas V, Meyers HP, Smith SW, Chartier LB. Missing occlusions: Quality gaps for ED patients with occlusion MI. Am J Emerg Med 2023; 73:47-54. [PMID: 37611526 DOI: 10.1016/j.ajem.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND ST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI vs OMI paradigms. METHODS This retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0-2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I >10,000 ng/L; or, if no angiogram, peak troponin >10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of "STEMI", and admission/discharge diagnoses were compared. RESULTS Among 382 patients, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were admitted as STEMI: 60.0% had "STEMI" on ECG, and median door-to-cath time was 103 min (IQR 71-149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had "STEMI" on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043-3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as "Non-STEMI." CONCLUSIONS STEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement.
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Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Emergency Department, University Health Network, Toronto, Ontario, Canada.
| | - Mazen El-Baba
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Centre and University of Minnesota, Minneapolis, MN, USA.
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Lee LK, Narang C, Rees CA, Thiagarajan RR, Melvin P, Ward V, Bourgeois FT. Reporting and Representation of Participant Race and Ethnicity in National Institutes of Health-Funded Pediatric Clinical Trials. JAMA Netw Open 2023; 6:e2331316. [PMID: 37647067 PMCID: PMC10469249 DOI: 10.1001/jamanetworkopen.2023.31316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/22/2023] [Indexed: 09/01/2023] Open
Abstract
Importance Enrolling racially and ethnically diverse pediatric research participants is critical to ensuring equitable access to health advances and generalizability of research findings. Objectives To examine the reporting of race and ethnicity for National Institutes of Health (NIH)-funded pediatric clinical trials and to assess the representation of pediatric participants from different racial and ethnic groups compared with distributions in the US population. Design, Setting, and Participants This cross-sectional study included NIH-funded pediatric (ages 0-17 years) trials with grant funding completed between January 1, 2017, and December 31, 2019, and trial results reported as of June 30, 2022. Exposures National Institutes of Health policies and guidance statements on the reporting of race and ethnicity of participants in NIH-funded clinical trials. Main Outcomes and Measures The main outcome was reporting of participant race and ethnicity for NIH-funded pediatric clinical trials in publications and ClinicalTrials.gov. Results There were 363 NIH-funded pediatric trials included in the analysis. Reporting of race and ethnicity data was similar in publications and ClinicalTrials.gov, with 90.3% (167 of 185) of publications and 93.9% (77 of 82) of ClinicalTrial.gov reports providing data on race and/or ethnicity. Among the 160 publications reporting race, there were 43 different race classifications, with only 3 publications (1.9%) using the NIH-required categories. By contrast, in ClinicalTrials.gov, 61 reports (79.2%) provided participant race and ethnicity using the NIH-specified categories (P < .001). There was racially and ethnically diverse enrollment of pediatric participants, with overrepresentation of racial and ethnic minority groups compared with the US population. Conclusions and Relevance This cross-sectional study of NIH-funded pediatric clinical trials found high rates of reporting of participant race and ethnicity, with diverse representation of trial participants. These findings suggest that the NIH is meeting its directive of ensuring diverse participant enrollment in the research it supports.
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Affiliation(s)
- Lois K. Lee
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston, Massachusetts
- Office of Health Equity and Inclusion, Boston Children’s Hospital, Boston, Massachusetts
| | - Claire Narang
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Chris A. Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Ravi R. Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston, Massachusetts
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Patrice Melvin
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston, Massachusetts
- Office of Health Equity and Inclusion, Boston Children’s Hospital, Boston, Massachusetts
| | - Valerie Ward
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston, Massachusetts
- Office of Health Equity and Inclusion, Boston Children’s Hospital, Boston, Massachusetts
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Florence T. Bourgeois
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
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Lee LK, Ellison A. The Responsibility of Addressing Health Disparities in Emergency Medicine. Ann Emerg Med 2023; 81:393-395. [PMID: 36841660 DOI: 10.1016/j.annemergmed.2023.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA.
| | - Angela Ellison
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Health Equity, Children's Hospital of Philadelphia, Philadelphia, PA
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Palacios-Fernandez S, Salcedo M, Belinchon-Romero I, Gonzalez-Alcaide G, Ramos-Rincón JM. Epidemiological and Clinical Features in Very Old Men and Women (≥80 Years) Hospitalized with Aortic Stenosis in Spain, 2016-2019: Results from the Spanish Hospital Discharge Database. J Clin Med 2022; 11:jcm11195588. [PMID: 36233458 PMCID: PMC9571913 DOI: 10.3390/jcm11195588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/29/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: The aging population poses challenges for hospital systems. Aortic stenosis is among the most frequent diseases in very old patients. The aim of this study was to describe gender and age differences in the clinical characteristics of very old patients hospitalized with aortic stenosis (AoS) in Spain from 2016 to 2019. (2): Methods: A retrospective observational study analyzing data from the national surveillance system for hospital data. Variables analyzed were age group, sex, length of stay, deaths, and comorbidity. (3) Results: The analysis included 46,967 discharges. Altogether, 7.6% of the admissions ended in death. The main reason for admission was heart failure (34.3%), and this increased with age (80−84 years: 26% versus 95−99 years: 56.6%; p < 0.001). The main treatment procedure was the transcatheter aortic valve replacement (12.7%), performed in 14.3% of patients aged 80−84 versus 0.5% in patients aged 95−99 (p < 0.001). In the multivariable analysis, women were admitted with more comorbidities (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.06−1.20). Mortality was similar, albeit women were admitted less for syncope (OR 0.83, 95% CI 0.74−0.93). Women also underwent fewer coronary catheterizations (OR 0.81, 95% CI 0.77−0.87) and echocardiograms (OR 0.96, 95% CI 0.94−0.98). (4) Conclusions: Aortic stenosis leads to a high number of hospital admissions. Women with AoS presented more heart failure and less cardiovascular pathology than men. Also, women are admitted with fewer episodes of syncope and have fewer ultrasounds and catheterizations.
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Affiliation(s)
| | - Mario Salcedo
- Department of Internal Medicine, San Pedro Hospital, 26006 Logroño, Spain
| | | | | | - José-Manuel Ramos-Rincón
- Department of Clinical Medicine, Miguel Hernandez University, 03550 Alicante, Spain
- Department of Internal Medicine, Alicante General University Hospital-Alicante Institute for Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain
- Correspondence:
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